Results of Chest Wall Resection and Reconstruction With and Without Rigid Prosthesis

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1 ORIGINAL ARTICLES: SURGERY: To participate in The Annals of Thoracic Surgery CME Program, please visit Results of Chest Wall Resection and Reconstruction With and Without Rigid Prosthesis Michael J. Weyant, MD, Manjit S. Bains, MD, Ennapadam Venkatraman, PhD, Robert J. Downey, MD, Bernard J. Park, MD, Raja M. Flores, MD, Nabil Rizk, MD, and Valerie W. Rusch, MD Department of Surgery, Thoracic Service, and Department of Epidemiology and Biostatistics, Biostatistics Service, Memorial Sloan Kettering Cancer Center, New York, New York Background. Chest wall resections are associated with significant morbidity, with respiratory failure in as many as 27% of patients. We hypothesized that our selective use of a rigid prosthesis for reconstruction reduces respiratory complications. Methods. The records of all patients undergoing chest wall resection and reconstruction were reviewed. Patient demographics, use of preoperative therapy, the location and size of the chest wall defect, performance of lung resection if any, the type of prosthesis, and postoperative complications were recorded. Predictor of complications were identified by 2 and logistic regression analyses. Results. From January 1, 1995, to July 1, 2003, 262 patients (median age, 60 years) underwent chest wall resection for tumor in 251 (96%), radiation necrosis in 7 (2.7%); and infection in 4 patients (1.3%). The median defect size was 80 cm 2 (range, 2.7 to 1,200 cm 2 ) and the median number of ribs resected was 3 (range, 1 to 8). Major lung resection was performed in 85 patients (34%). Prosthetic reconstruction was rigid (polypropylene mesh/ methylmethacrylate composite) in 112 (42.7%), nonrigid (polytetrafluoroethylene or polypropylene mesh) in 97 (37%), and none in 53 patients. Postoperatively, 10 patients died (3.8%), 4 of whom had pneumonectomy plus chest wall resection. Respiratory failure occurred in 8 patients (3.1%). By multivariate analysis, the size of the chest wall defect was the most significant predictor of complications. Conclusions. Our incidence of respiratory failure is lower than previously reported and may relate to our use of rigid repair for defects likely to cause a flail segment. Pneumonectomy plus chest wall resection should be performed only in highly selected patients. (Ann Thorac Surg 2006;81:279 85) 2006 by The Society of Thoracic Surgeons The most common indications for chest wall resection include tumor (primary, recurrent, metastatic, or locally invasive), radiation necrosis, infection, or trauma [1]. The management of such chest wall lesions includes resection and skeletal reconstruction and soft tissue coverage of the defect. The decision to perform skeletal reconstruction with exogenous materials that will prevent a flail chest and subsequent respiratory failure is crucial to the successful management of these lesions. Soft tissue coverage of the reconstructed chest wall is equally important and various techniques of tissue transfer have been employed to cover these defects. Early attempts at chest wall resection were limited by availability of suitable materials for reconstruction. Initial materials consisted of autogenous tissue such as fascia lata grafts, rib grafts, or large cutaneous grafts [2, 3]. Since the 1980s, the use of prosthetic materials including polytetrafluoroethylene (PTFE), polypropylene mesh (PPM) and polypropylene mesh methylmethacrylate composites combined with the use of myocutaneous flaps has Accepted for publication June 5, Address correspondence to Dr Rusch, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021; ruschv@mskcc.org. enabled successful reconstruction of even the largest chest wall defects [4]. However, despite these modern techniques for chest wall reconstruction, complications after chest wall resection are common and are reported to occur in 37% to 46% of patients. Respiratory complications continue to be the most frequent and are reported in 20% to 24% of patients [1, 4]. The high incidence of respiratory complications has been attributed to the presence of a flail segment of chest wall after reconstruction, leading to poor pulmonary toilet and subsequently respiratory failure. Other frequent complications include supraventricular arrhythmias and wound complications [1, 4, 5]. Since we first described the technique of chest wall reconstruction with a polypropylene mesh methylmethacrylate composite (Marlex mesh methylmethacrylate sandwich) in 1981, it has been our practice to use this form of rigid reconstruction routinely in most anterior or lateral defects considered likely to produce chest wall instability [6]. We report our modern experience with chest wall resections to determine the frequency and severity of postoperative complications, and to identify factors that may be associated with complications after chest wall resection by The Society of Thoracic Surgeons /06/$32.00 Published by Elsevier Inc doi: /j.athoracsur

2 280 WEYANT ET AL Ann Thorac Surg COMPLICATIONS AFTER CHEST WALL RESECTION 2006;81: Material and Methods Table 1. Histology of Resected Chest Wall Lesions Histology Nonsmall cell lung carcinoma 99 Sarcoma 75 Breast carcinoma 26 Mesothelioma 9 Colonic adenocarcinoma 6 Desmoid tumor 9 Other malignant tumors 18 Benign tumors 9 Radiation necrosis 7 Infection 4 Total 262 After approval of this study by our Institutional Review Board, the medical records of all patients undergoing chest wall resection on the Thoracic Surgery Service at Memorial Sloan-Kettering Cancer Center (MSKCC) from January 1, 1995 to June 30, 2003, were retrospectively reviewed. This period was selected because it represents a modern experience during which electronic medical records were available, allowing for uniformly accurate data retrieval. Patients undergoing chest wall resection for post-thoracotomy empyema (modified Eloesser flap procedures) were excluded from this study. The preoperative data collected included patient demographics, medical comorbidities, and use of preoperative chemotherapy or radiotherapy. Surgical data were obtained from operative reports and included the location of the chest wall lesion, the number of ribs resected, whether lung resection was also performed, and the methods of skeletal and soft tissue reconstruction. Anterior chest wall defects were defined as being located between the sternum to the anterior axillary line; lateral as located between the anterior and posterior axillary lines, and posterior defects as located between the spine and posterior axillary line. The size of the chest wall defect and the histological diagnosis were obtained from the final pathology report. Skeletal reconstruction was categorized as a rigid prosthesis, a nonrigid prosthesis, or no prosthesis. Rigid prosthetic reconstruction consisted of a Marlex mesh (Bard, Cranston, Rhode Island) methylmethacrylate (Simplex P; Stryker Howmedica Osteonics, Mahwah, New Jersey) sandwich (MMM). This was a modification of our previously described technique, in which methylmethacrylate is applied within a double layer of Marlex mesh tailored to the size and contour of the chest wall defect [6]. An additional layer of wire mesh, described in the original technique, was not used because the stability of the prosthesis was found to be adequate without this. Nonrigid reconstruction consisted either of PPM alone or expanded PTFE (W. L. Gore & Associates, Flagstaff, Arizona) alone. Postoperative analgesia was provided as a continuous narcotic infusion through an epidural catheter. In the rare circumstance in which epidural analgesia was precluded by technical problems, intravenous patient-controlled analgesia was used. Complications were considered as perioperative if they occurred within 30 days of surgery. Complications specific to the technique of reconstruction were included for analysis if they occurred within 90 days after surgery. Pneumonia was defined as localized pulmonary infiltrates with culture-positive identification of a pathogenic organism. Pneumonitis was defined as culture-negative, localized pulmonary infiltrates. Respiratory failure was defined as hypoxia without evidence of a pathogenic organism, bilateral or diffuse pulmonary infiltrates, or other identifiable cause, such as pulmonary embolism. Prolonged air leak was defined as a chest tube air leak of more than 7 days postoperatively. All complications were graded according to the National Cancer Institute Common Toxicity Criteria for Adverse Events, version 3.0 (CTCAE 3.0. Available at: reporting/ctc.html) [7]. The distribution of the size of the chest wall defect across the three prosthesis groups was compared using the Kruskal-Wallis test. Factors predicting complications were analyzed univariately using 2 test for categorical variables and logistic regression for continuous variables. Multivariate analysis was performed using all variables that showed some significance in the univariate analysis (p 0.1). Prosthesis type was included in the model. No stepwise procedure was used. Results Patient Data During the study period, 262 patients underwent chest wall resection at MSKCC. There were 123 female patients (47%) and 139 male patients (53%) with a median age of 60 years (range, 18 to 89). The indications for resection were tumor in 251 patients (96%), radiation necrosis in 7 (2.7%), and infection in 4 (1.3%). Tumors were metastatic or recurrent in 100 (38%), primary chest wall tumors in 79 (30%), and contiguous primary lung cancer in 85 (32%). Prior or immediate preoperative therapy was given to a total of 145 patients (56%), of whom 42 (16%) received chemotherapy only, 27 (10%) received radiation only in the area of resection, and 76 (29%) received both. Associated medical comorbidities included chronic obstructive pulmonary disease in 27 patients (10%), diabetes mellitus in 20 (8%), coronary artery disease in 19 (7%), and hypertension in 61 (23%). The most common histologic findings were nonsmall cell lung carcinoma, bone or soft tissue sarcoma, and breast carcinoma (Table 1). Our routine perioperative management was early extubation, usually in the operating room at the end of the procedure, then an overnight stay in the recovery room, and transfer to the thoracic surgical ward on the first postoperative day. The median length of stay for all patients was 7 days (range, 1 to 67) Surgical Data Prosthetic materials were used to reconstruct the chest wall defects in 209 patients (79.8%; 112 with a rigid n

3 Ann Thorac Surg WEYANT ET AL 2006;81: COMPLICATIONS AFTER CHEST WALL RESECTION 281 Table 2. Characteristics and Outcome of Different of Methods of Reconstruction After Chest Wall Resection Variable Rigid (MMM) (n 112) Nonrigid (PTFE or PPM) (n 97) None (n 53) p Value Median age, years (range) 62 (20 82) 57 (18 89) 59 (34 86) 0.09 a Median no. ribs (range) 3 (1 8) 3 (1 6) 3 (1 4) a Median size of chest wall defect, cm 2 (range) (23 1,200) b 71 ( ) 42 (3 187) Median length of stay, days (range) 7.5 (3 62) 6 (2 67) 7 (1 29) day complications 43 (38.4%) 26 (27.0%) 18 (33.9%) 0.26 Mortality 5 (4.5%) 3 (3.1%) 2 (3.8%) day complication of reconstruction 15 (13.4%) 7 (7.2%) day prosthesis removal 5 (4.5%) 4 (4.1%) c 0.33 a The differences in age and in the number of ribs are significant because of the differences in distribution across the stated ranges for these values. b The size of the defects reconstructed with MMM is significantly larger than other methods (p 0.001). c One patient returned to the operating room early postoperatively and had PTFE replaced with MMM owing to respiratory failure. MMM Marlex mesh methyl-methacrylate sandwich; PPM polypropylene mesh; PTFE polytetrafluoroethylene. prosthesis and 97 with nonrigid material). The lesions were located in the anterior chest wall or sternal region in 107 patients, posteriorly in 91and laterally in 64 patients. Lesions in the anterior and sternal locations were more frequently repaired with a rigid prosthesis (Table 2), whereas posterior and lateral defects were repaired more frequently by PTFE and PPM (p 0.001). The size of the chest wall defects ranged from 2.7 to 1,200 cm 2 (median, 81 cm 2 ). The size of the defect was significantly larger in patients who had reconstruction with a MMM prosthesis as compared with those who had a nonrigid or no reconstruction. The median number of ribs resected was 3 (range, 1 to 8). However, patients who had a MMM reconstruction overall had significantly more ribs resected (Fig 1). Concomitant lung resection was performed in 141 patients (54%), with 49 (18.7%) having a wedge resection, 6 (2.3%) having segmentectomy, 74 (28.2%) having lobectomy, 3 (1.5%) having bilobectomy, and 9 (3.4%) having pneumonectomy. Procedures were reoperative (ie, second resection in same area or same hemithorax as first resection) in 59 patients (23%). Some form of sternal resection was required in 49 patients (18.7%), including partial sternectomy in 34 (13%), manubrium resection in 9 (3.4%), and total sternectomy in 6 (2.3%). Primary soft tissue closure was achieved in 211 patients with transposed tissue or muscle being required in 51(19%). When transposed tissue was required, pedicled myocutaneous flaps were used most frequently, being utilized in 38 patients, followed by free myocutaneous flaps in 8 and rotation/advancement flaps in 5 patients. The most common sources of the transposed tissue were rectus abdominus in 22 patients, pectoralis major in 15, and latissimus dorsi in 15, followed by omentum in 4 patients, serratus in 1, and forearm (from an adjacent forequarter amputation) in 1 patient. Fig 1. Number of ribs resected in each patient group. (Black bars none; dark gray bars nonrigid; light gray bars rigid; unk unknown.)

4 282 WEYANT ET AL Ann Thorac Surg COMPLICATIONS AFTER CHEST WALL RESECTION 2006;81: Table 3. Most Common Complications of Chest Wall Resection With a Severity Grading a Complication Grade 1 (Mild) Grade 2 (Moderate) Grade 3 (Severe) Grade 4 (Life- Threatening or Disabling) Grade 5 (Death) Pneumonia Pneumonitis 4 1 Hypoxia/respiratory failure Atelectasis 8 Aspiration 1 Pleural effusion 3 Prolonged air leak Arrhythmia 17 Wound infection 6 8 Wound dehiscence 1 2 Flap hematoma 3 Hemorrhage 3 Deep vein thrombosis 5 a According to CTCAE 3.0. Available at: Complications A total of 114 complications occurred in 87 patients (33.2%) within the postoperative period. The most frequent types of complications and their severity are listed in Table 3. The most common complications were respiratory, occurring in 29 patients (11%), and included respiratory failure in 8 (3.1%), pneumonitis in 5 (1.9%), pneumonia in 7 (2.7%), atelectasis requiring bronchoscopy in 8 (3.1%), and aspiration in 1 (0.4%). Ten patients (3.8%) died as a result of postoperative complications. Seven of the 10 deaths occurred as a result of respiratory complications. The other 3 patients (not shown in Table 2) died of intestinal ischemia (2 patients) and sepsis (1 patient). The mortality rate for all patients undergoing some kind of lung resection was 5.6%. The small number of patients undergoing pneumonectomy combined with chest wall resection had a mortality rate of 44% (4 of 9). Wound complications occurred in 19 patients (7%). Wound dehiscence occurred in 3 patients (1%), all of which were grade 3 (requiring operative debridement or repair). Flap hematoma requiring reoperation occurred in 3 patients. No transposed tissue or muscle flaps were lost to necrosis. Wound infections occurred in 14 patients (5.3%), leading to removal of prosthesis in 8 (3.8%). One patient had a PTFE prosthesis removed and replaced with MMM early in the postoperative period because of respiratory failure thought to be related to chest wall instability. After insertion of the MMM prosthesis, the patient made an uncomplicated recovery. There was no significant difference in complication rates among prosthetic groups when all types of complications at 30 days were analyzed. However, when the two most common groups of complications were considered, there was no significant difference in respiratory complications among prosthetic groups, but MMM prostheses had a significantly higher number of wound complications (Table 4). Factors associated with postoperative complications were analyzed. The type of prosthesis, the location of the lesion, the need for sternal resection, medical comorbidities, prior radiotherapy or chemotherapy, reoperation, type of soft tissue reconstruction, or the use of subcutaneous drains were not significant predictors of postoperative complications. Univariate analysis identified patient age, size of the chest wall defect, and lung resection greater than wedge resection to be significant predictors of postoperative complications (Table 5). Multivariate analysis showed that patient age, extent of pulmonary resection, and defect size significantly predicted postoperative complications (Table 6). Comment Surgical treatment of these lesions often involves removal of a full-thickness portion of the chest wall, which in turn leaves a segment of chest wall vulnerable to paradoxic motion during respiration. The importance of chest wall reconstruction is illustrated by historical and Table 4. Differences in the Most Common Types of Complications Analyzed by Type of Reconstruction Complication No Reconstruction Nonrigid Reconstruction Rigid (MMM) Reconstruction p Value a Respiratory Wound a Analyzed by the Fisher exact test. MMM Marlex mesh-methyl-methacrylate sandwich.

5 Ann Thorac Surg WEYANT ET AL 2006;81: COMPLICATIONS AFTER CHEST WALL RESECTION 283 Table 5. Univariate Analysis of Predictors of Complications After Chest Wall Resection Complications p Value recent reports of the treatment of traumatic flail chest, which suggest that patients with large flail segments benefit from chest wall stabilization, which in turn decreases pulmonary complications and length of ventilatory support [8]. There is some controversy as to which chest wall lesions should be reconstructed but, generally, lesions less than 5 cm in size in any location, and those up to 10 cm in size posteriorly do not need reconstruction for functional reasons [4]. Posterior defects in proximity to the tip of the scapula, larger lesions likely to produce No Yes Categorical Variables Total number of patients Prosthesis Nonrigid Rigid None Location Anterior Lateral Posterior Sternal resection No Yes Lung resection None Wedge resection Lobectomy or pneumonectomy Medical comorbidity No Yes Prior radiotherapy No Yes Prior chemotherapy No Yes Reoperation No Yes Soft tissue transfer No Yes Drains No Yes Continuous variables Age: median 60 years 0.01 (range, 18 89) Size: median 80.9 (range, ) 0.01 paradoxical chest wall motion and most anterior defects, require reconstruction. The prosthetic materials used most commonly include PPM, PTFE, and MMM. The use of a rigid prosthesis using a PPMmethylmethacrylate sandwich was developed by one of the authors of this study (M.S.B.) and has since been widely adopted [4, 6, 9, 10]. It is our practice to use this rigid prosthesis for those defects likely to produce a flail segment, including large anterior or lateral lesions, or the area of the sternum in which some protection of the underlying organs is essential. This technique provides rigid repair that can be tailored to any size, shape, or contour of chest wall defect. The present report represents the most extensive experience with the use of this method of reconstruction. Complications after chest wall resection are common and range from 46% to 69% in two of the largest recent series of chest wall resection [1, 4]. Respiratory complications including pneumonia, acute respiratory distress syndrome, and atelectasis are by far the most common (Table 6) and have been reported to be as high as 24% [1]. Wound complications such as infection, dehiscence, flap loss, and hematoma are reported to occur in 8% to 20% [1, 4, 9]. These series represent single-institution experience over multiple decades and therefore do not represent the summation of improvements in surgical technique, reconstructive materials, and postoperative care. In addition, previous series have not uniformly reported respiratory complications or used a grading system to quantify the severity of complications (Table 7). The CTCAE 3.0, an internationally accepted system used to report adverse events in cancer clinical trials, provides a precise method of defining postoperative complications [7]. Utilizing this grading system, we found that most complications were grades 1 to 3, and not life-threatening. Our recent experience demonstrates that respiratory complications occurred in 11% of patients and included pneumonia, pneumonitis, atelectasis, and respiratory failure (adult respiratory distress syndrome). Respiratory complications contributed to 7 of 10 deaths after chest wall resection and 12 of 28 patients (43%) with respiratory complications had either grade 4 or 5 events, indicating either severe disability or death. Although this frequency of complications is far less than in other series [1, 4], our experience reiterates the fact that respiratory complications remain a significant problem. Table 6. Multivariate Analysis of Predictors of Complications After Chest Wall Resection Variable Odds Ratio p Value 95% CI Patient age (in 10-year units) Prior radiotherapy Wedge resection Lobectomy or pneumonectomy Sizes of chest wall defect (in log scale) CI confidence interval.

6 284 WEYANT ET AL Ann Thorac Surg COMPLICATIONS AFTER CHEST WALL RESECTION 2006;81: Table 7. Complications and Mortality after Chest Wall Resection in Previously Published Series Author Year Number of Patients Respiratory Complications Morbidity Mortality Mansour % 24% 7% Deschamps % 46% 4.1% Pairolero NR NR 3.0% McKenna NR NR 3.6% NR not reported. It is unclear whether surgical technique, careful selection for use of a rigid prosthesis, or both, minimize the possibility of postoperative respiratory complications. Advances in anesthetic management and perioperative care surely play a role in the improved outcome of these patients. However, the use of rigid prosthesis and its influence on respiratory mechanics, especially for large chest wall defects or those located anteriorly or laterally, cannot be discounted. Lardinois and coworkers [10] recently reported their experience with 26 patients having chest wall resection and reconstruction with MMM. The authors report that there was no 30-day mortality and nearly all patients had a satisfactory cosmetic and functional outcome. There was no significant difference in preoperative and postoperative forced expiratory volume at 1 second even among those patients undergoing wedge resection or lobectomy. The prostheses were imaged with cine-magnetic resonance imaging and found to exhibit no paradoxic chest wall motion in any patient [10]. In our series, 1 patient who initially had respiratory failure clearly benefited by replacement of a nonrigid prosthesis with a rigid MMM composite early in the postoperative period. In addition, there was no significant difference in respiratory complications in patients undergoing MMM reconstruction as compared with the other two groups, even though these patients had significantly large chest wall defects. Although our findings do not unequivocally prove the superiority of MMM reconstruction, they certainly emphasize the efficacy of this prosthesis for very large defects that would otherwise leave the patient with a flail chest. Few prior series have analyzed possible risk factors contributing to postoperative complications after chest wall resection [4]. Risk factors that may predispose to postoperative complications either by altering respiratory mechanics or the wound environment include the type of prosthesis, patient age, the size of the chest wall defect, the addition of sternal resection, concomitant lung resection, medical comorbidities, prior use of chemotherapy or radiotherapy, reoperation, and the type of soft tissue reconstruction. We identified patient age, size of the chest wall defect, and concomitant anatomical lung resection as predictors of postoperative complications by multivariate analysis. It is not surprising that patient age (and especially age more than 60 years) is associated with morbidity given the scope of many of these operations. It may also seem obvious that the larger a chest wall resection, the more likely are postoperative complications. However, most previous series have measured the size of the lesion only by the number of ribs resected, which does not reflect the size of a chest wall defect accurately because of the variations in size for a posteriorly versus an anteriorly located defect. Concomitant lung resection has been reported by others to have an adverse effect on postoperative mortality [4]. That is not surprising as these patients have respiratory function compromised not only by reduction in lung volume but also in change in the rigidity of the chest wall. We were not able to perform an analysis of mortality risk factors because of the small number of postoperative deaths, but the combination of pneumonectomy and chest wall resection appears to be associated with an especially high mortality. Although MMM prostheses provide excellent chest wall stability and a low risk of respiratory complications, they were associated with a greater number of wound complications. It is impossible for us to determine within the context of a retrospective study in a heterogeneous patient population whether these wound complications relate to the prosthesis itself or to the size of the chest wall defects or other factors such as the length of the operation or form of soft tissue reconstruction. In recent years, we have often modified the MMM prosthesis by using cross-hatching strips of methylmethacrylate rather than creating an entirely solid plate. This variation provides excellent stability but also allows some tissue ingrowth and better fluid drainage from the chest wall soft tissues into the pleural space than does a nonporous plate of methylmethacrylate. Future studies will be required to determine if this variation in reconstructive technique yields a superior result. In conclusion, respiratory complications continue to be the main source of morbidity after chest wall resection. The frequency of respiratory complications in our series is less than in other reported series and supports our routine use of a rigid prosthesis for reconstruction of the large, anteriorly or laterally located defects that would otherwise cause a flail chest postoperatively. Our results also emphasize the importance of considering patient age and the need for anatomical resection, especially pneumonectomy, when planning chest wall resection and reconstruction. The authors wish to acknowledge that some of the patients in this series were operated on by the late Drs Michael Burt and Robert Ginsberg, and by Dr Patricia McCormack, now retired. The authors also thank Melody Owens for her expert assistance in manuscript preparation. References 1. Mansour KA, Thourani VH, Losken A, et al. Chest wall resections and reconstruction: a 25-year experience. Ann Thorac Surg 2002;73:

7 Ann Thorac Surg WEYANT ET AL 2006;81: COMPLICATIONS AFTER CHEST WALL RESECTION Carbone M, Pastorino U. Surgical treatment of chest wall tumors. World J Surg 2001;25: Arnold PG, Pairolero PC. Chest wall reconstruction: an account of 500 consecutive patients. Plast Reconstr Surg 1996;98: Deschamps C, Tirnaksiz BM, Darbandi R, et al. Early and long-term results of prosthetic chest wall reconstruction. J Thorac Cardiovasc Surg 1999;117: Sabanathan S, Shah R, Mearns AJ. Surgical treatment of primary malignant chest wall tumours. Eur J Cardiothorac Surg 1997;11: McCormack P, Bains MS, Beattie EJ Jr, Martini N. New trends in skeletal reconstruction after resection of chest wall tumors. Ann Thorac Surg 1981;31: Trotti A, Colevas AD, Setser A, et al. CTCAE v3.0: development of a comprehensive grading system for the adverse effects of cancer treatment. Sem Rad Oncol 2003;13: Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma 2002;52: McKenna RJ Jr, Mountain CF, McMurtrey MJ, Larson D, Stiles QR. Current techniques for chest wall reconstruction: expanded possibilities for treatment. Ann Thorac Surg 1988; 46: Lardinois D, Müller M, Furrer M, et al. Functional assessment of chest wall integrity after methylmethacrylate reconstruction. Ann Thorac Surg 2000;69: INVITED COMMENTARY Optimal management to improve early clinical outcomes after chest-wall resection (CWR) reflects the variable cause, presentation, and treatment options for this surgical problem. Chest wall neoplasms (primary, metastatic, or local involvement by lung cancer) can involve any aspect of the boney thorax and sternum, and can be highly variable in size and biological virulence. Such variability limits prospective clinical investigations. In this article, a contemporary large retrospective review of early (postoperative) outcomes after CWR is presented that provides additional insights into relating these early outcomes to treatment decisions. Approximately one third of the patients had either metastatic or recurrent tumors to the chest wall or primary chest-wall tumor, or had chest wall involvement by direct extension of lung cancer. In addition to CWR, major lung resection (lobectomy or greater) was performed in 34% of all patients. Areas of CWR were anatomically defined, accurately measured (cm 2, not number of ribs), and analyzed. In general, patients with anterior CWR and sternal resections were reconstructed with rigid prostheses. The low number of patients with pulmonary events (29 patients; 11%) reflect reconstruction with rigid prostheses and improved general pulmonary care in this series. The mortality was 3.8% (10 patients); respiratory events were the cause of 7 of 10 deaths, including 4 patients with pneumonectomy plus CWR. Multivariate analysis identified older age, concomitant anatomical lung resection, and larger defect size as significant adverse variables. Attenuation of early postoperative respiratory events will further improve clinical outcomes. Correlation with preoperative spirometry could be helpful in assisting with patient selection, preparation for resection, determination of the extent of resection, and the technique of reconstruction. This review of early clinical outcomes after CWR provides a basis for improving perioperative and intraoperative care processes [1]. Iterative improvements are possible and could be focused on precise choice of reconstruction technique and improving perioperative pulmonary function. The use of rigid reconstruction seems to enhance early postoperative pulmonary function, particularly after larger CWRs. The current and future use of The Society of Thoracic Surgeons general thoracic surgery database will provide further insight into reconstruction techniques and outcomes from patients undergoing chest wall resection, a variable and challenging population. Joe B. Putnam, Jr, MD Department of Thoracic Surgery Vanderbilt University 2971 The Vanderbilt Clinic nd Ave S Nashville, TN bill.putnam@vanderbilt.edu Reference 1. Weyant MJ, Bains MS, Venkatraman E, et al. Results of chest wall resection and reconstruction with and without rigid prosthesis. Ann Thorac Surg 2006;81: by The Society of Thoracic Surgeons /06/$32.00 Published by Elsevier Inc doi: /j.athoracsur